February 14, 2014

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arousal ›   women's sexual health ›  


Q: Can love lead back to desire?

First, let me assure you that you're not alone in feeling a loss of libido: It's common for women to lose desire, even in great, emotionally supportive relationships.

Low desire is challenging to treat, because we women are complex sexual creatures. I prescribe testosterone for some of the women in my practice; about 60 percent of those who've tried it have found that it does boost libido. I wish it were 100 percent, but it's not! And some physicians are reluctant to prescribe testosterone for women because it's "off-label."

Given what we know about women's sexuality, I advise women to engage "mindfulness" when it comes to sex. Often, we feel desire somewhere in the process of being intimate; we may not be driven to intimacy by desire. We need to choose to be sexual! I encourage women to plan for sex, committing to a frequency that is comfortable for both partners. It might be once a week, once a month, on Friday evening or Sunday morning—whenever you're least likely to be distracted, stressed, or tired. When we have been sexual, we've typically found it pleasurable and we're glad we did!

Finally, you mention being self-conscious about your breasts, which are no longer like they used to be. We are our own worst enemies when it comes to body image, and we pay the price when we rob ourselves of pleasures! I'll bet your partner doesn't look like he used too, either, and that he loves every inch of your body, as you love his. You might reread this blog post on body image and try some of the suggestions to "send your body some luv."

Models of Desire

Women are not men. No surprise, right? In many parts of our lives, we know that.

When it comes to sex, though, many of our expectations—and those of the experts who advise us—are still based on expecting that men and women are more alike than not. And women are not men.

There’s an important implication from the model for women’s sexuality I’ve shared before, the one developed by Rosemary Basson, of the University of British Columbia. Women are not men: While men quite predictably experience desire and then arousal, women don’t. Sometimes, actually, women don’t experience desire until midway into lovemaking.

No big deal, you’re thinking? I wish.

Unfortunately, the messages we’ve internalized affect the way we behave and what we believe about ourselves. I’ve talked about hypoactive sexual desire disorder (HSDD) before, and it’s something I regularly talk about with women in my practice. There are hormonal changes, reactions to prescriptions, and other factors that can lead to HSDD, which is real and deserves attention from researchers and pharmaceutical companies.

But sometimes what we wish we could fix with a pill is actually the fact that we’re women, not men. If we, as women, expect to respond sexually as men respond, we’re more likely to misread our reality as “lack of libido.”

Which leads to the other reason I think understanding Rosemary’s model is a big deal. I talk to women who are at some point in a vicious cycle: They don’t experience interest as they used to; some physical changes have made intimacy uncomfortable or even painful; they begin to avoid sex; the physical changes continue; and intimacy becomes even more uncomfortable. How do we reverse this sequence? Or avoid the slide into it?

We can start with the reasons—beyond the hormones that drove us at 27—that we might want to be sexually intimate with a partner: to please him, to experience closeness, to cement our relationship, as an apology, a thank-you—or because we want to feel our own liveliness, sensuality, and power!

Kama Sutra Massage OilsAnd then we can trust that desire will come into the picture, if we’re having the kind of sex that arouses us. Michael Castle wrote about this in Psychology Today: “Sex that fuels desire is leisurely, playful, sensual…. based on whole-body massage that includes the genitals but is not limited to them.” Castle says women often complain that men are “too rushed, and too focused on the breasts, genitals, and a quick plunge into intercourse.” That kind of lovemaking doesn’t allow space for women to experience desire.

He points out, too, that leisurely, sensual sex is also recommended by sex therapists to men dealing with premature ejaculation or erectile dysfunction. Happily, the kind of sex that fuels women’s desire is also good for their partners.

Women are not men. We can recognize, internalize, and celebrate our difference. We can be sure we’ve communicated with our partners what we like when we make love. We can let go of any expectations except our own. We are women.

You're Not Alone

It’s going on eight years since I transformed my medical practice. I studied and became certified by the North American Menopause Society as a menopause care provider, and while welcoming patients into my practice, used their questionnaire — a thorough document that makes it easy for new patients to give me a comprehensive view of their symptoms and health histories.

On that eight-page-long form there are just a few questions for women to answer about their current and past sexual experiences:

  • Do you have concerns about your sex life?
  • Do you have a loss of interest in sexual activities (libido, desire)?
  • Do you have a loss of arousal (tingling in the genitals or breasts; vaginal moisture, warmth)?
  • Do you have a loss of response (weaker or absent orgasm)?
  • Do you have any pain with intercourse (vaginal penetration)? If yes, how long ago did the pain start? Please describe the pain: Pain with penetration? Pain inside? Feels dry?
I continue to be amazed by the responses from my patients. Sixty percent of my patients have experienced a loss of interest in sexual activities, 45 percent have a loss of arousal, and 45 percent a loss of sexual response. And when I talk to them, they are
  • Perplexed—because they don’t understand what’s changed.
  • Disappointed—because they expected there to be more.
  • Frustrated—because they don’t know what to do about it.

And when you carry those numbers from my practice to the rest of the country–well, more than 44 million women are aged 40 to 65 in the US alone. Some 6,000 of us reach menopause every day. And at least half of us experience sexual problems with menopause. Probably more.

That’s a lot of disappointed women. And a lot of disappointed men, too.

But you know what it means? Those symptoms you think are setting you apart, making you the odd woman out? They’re not unusual. You’d be more unusual if you sailed through perimenopause and menopause without symptoms.

So speak up! Talk to your health care provider about what you’re experiencing. Read sites like ours to learn more about your options for compensating for changes that aren’t making you happy. Talk to your friends and sisters about your experiences.

We don’t give up reading when our eyesight weakens—we snag some cheaters from the drugstore. We don’t have to just accept the changes if we don’t want to. We’re smart, resourceful, and can do what it takes to live the lives we want to live.

January 21, 2014

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arousal ›   self-care ›  


It Starts with Thinking

My last blog post, about thinking about sex as we think about exercise to encourage us to keep our sexuality alive, reminded me of another article I saw a while back.

In “Men Don’t Think about Sex Every Seven Seconds,” Dr. Laura Berman set out to debunk the urban legend alluded to in the headline. She cited a study done at Ohio State University, which concluded that men think about sex, on average, 19 times a day; women think about sex about 10 times a day.

That’s a far cry from every seven seconds, which works out to somewhere over 8,000 times per day, if my math is right and assuming eight hours of sleep.

Now, that research was done with college-age men and women, and I’m willing to cross-reference the National Surveys of Sexual Attitudes and Lifestyles (NATSAL), recently completed in Britain, to guess that by midlife, the rate is reduced by as much as 60 percent. For women like me, that means thinking about sex three or four times a day.

I don’t know how that strikes you—as too much or too little! Laura made another comment in her article that resonates with what I’ve seen in my practice: Researchers “found that incidence of sexual thoughts were most highly governed by one’s own sexual belief system. …People who had anxiety, shame, or guilt around their sexuality were less likely to have sexual thoughts, while people who were comfortable and secure in their sexuality were more likely to have sexual thoughts.”

That’s especially important to us as midlife women. We get lots of messages that conflict with the reality that we are still vital, complete, sensual, sexual creatures. As we watch our bodies change—through childbearing, decades, illness, losing and gaining (and losing and gaining) weight, new wrinkles—we ourselves sometimes question whether we are still sexual, attractive to ourselves as well as to our partners.

Dissatisfaction with our bodies is hardly exclusive to us midlife women, sadly. But when it affects what we decide to do or not to do, it begins to matter more to us. You’ve no doubt seen articles about staying active, because the more active you remain as you grow older, the more active you’re able to remain. You keep muscle tone, bone mass, and balance only as you exert yourself.

The same is true of our sexual selves. Physically, being sexually engaged increases circulation to vaginal tissues, which naturally thin and become more fragile as we lose estrogen. It’s equally important that we’re attuned to the mental part of the equation.

Remember Stuart Smalley on Saturday Night Live? The nerdy guy with the affirmations? “I’m good enough, I’m smart enough, and doggone it, people like me.” What if we midlife women had affirmations for ourselves? Could we use them to both reclaim our bodies and nurture our sexual selves?

I’ll have to give that some thought. Possibly up to ten times a day.

January 13, 2014

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anatomy ›   arousal ›   comfort ›   conditions ›   hormones ›  


Q: Why do I have pain and hypersensitivity?

What you describe—pain and a burning sensation around your clitoris—is most consistent with vulvovaginal atrophy. As we lose estrogen, the genital tissues thin, and the labia and clitoris actually become smaller. There's also less blood supply to the genitals. Beyond making arousal and orgasm more difficult to achieve, these changes can also lead to discomfort, and experiencing pain when you're looking for pleasure will certainly affect your sex drive and arousal!

Localized estrogen is the option that works best (and it's often a huge difference) for most of my patients, restoring tissues and comfort. Talk to your health care provider about the available options and what you might consider in choosing one.

A vaginal moisturizer can also help you restore those tissues, but I suspect you'll find that most effective in combination with localized estrogen.

Please do take steps to address your symptoms! If sex can be more comfortable and enjoyable for you, I'm hopeful that your sex drive will rebound.

January 02, 2014

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arousal ›   conditions ›   hormones ›  


Still Seeking Options

We’ve been following the development of Flibanserin, also called “pink Viagra,” since 2010, when its developer shelved it after hitting a bump in the road to FDA approval. Several years later, we were talking about alternatives, Librido and Lybridos, which were moving forward with clinical trials (and have not yet been approved).

We’ve just learned that the manufacturer that now owns Flibanserin has filed an appeal of the FDA denial, saying that other drugs have been approved with less data and more extreme side effects. And that’s reignited discussion about whether pharmaceutical products targeting women’s sexual disorders are evaluated on a level—or relevant—playing field.

Flibanserin, Librido, and Lybridos (and a small handful of others) are all drugs designed to play a part in awakening libido for women. They counter hypoactive sexual desire disorder (HSDD), in physicians’ terminology (the rest of us call it “not tonight—or tomorrow night, either” syndrome). There are, for context, a couple of dozen FDA-approved drugs for the comparable problem among men, including Viagra.

I don’t have the insider information I’d need to assert a double standard, although people I know and respect—like my colleague Sheryl Kingsberg—suggest there is one. Women’s health psychologist at University Hospitals MacDonald Women’s Hospital, Sheryl said, “There’s a double standard of approving drugs with a high risk for men versus a minimal risk for women.” The side effects for Flibanserin, for example, were reported as dizziness and nausea; Sheryl compares those to side effects of penile pain, penile hematoma, and penile fracture—all from a drug that was approved.

That does sound like some extra protectiveness of women. Given my focus on sexual health for women, I run into a lot of cultural expectations and hesitations; we Americans are still just a bit prudish when it comes to, especially, older women having sex. That’s in spite of what I see in my practice every day: Women themselves want to live whole lives, which means being physically active, emotionally engaged, and sexually active within their relationships.

I recognize that sexuality for women is complex, and there won’t be a “magic bullet.” For women, arousal and desire is a mix of emotional intimacy, biological responses, and psychological responses; a drug won’t address all of the components. But because I’m often working with patients to untangle interlocking causes of problems with sex, I’m eager for as many tools as possible, including pharmaceuticals.

As a physician, I also see the need to evaluate trade-offs and risks. I’ve talked before about the pros and cons of hormone therapy. For some women, living longer doesn’t really count if they’re not able to be active—including being actively sexual. “Pink Viagra” drugs may well require the same kind of close collaboration between women and their doctors to evaluate risks and benefits. Again, Sheryl: “Give women a chance to decide for themselves, within reason. There is no drug out there that has no risk.” In the case of Flibanserin, only 8 percent of testers said the side effects were bad enough to make them want to drop the drug.

These decisions by the FDA are also important because pharmaceutical research is done by businesses, businesses that can decide that one problem or another is too expensive or too complicated to take on. Sheryl sees this, too, saying, “My worry is that research in this area will dry up and will leave many women without a pharmacological option.”

One way to make your voice heard about the importance of continued research is by signing the International Society for the Study of Women’s Sexual Health (ISSWSH) WISH petition. Our sexual health is integral to our overall health, and we need more investigation and even-handed, common-sense consideration of therapies for women.

December 12, 2013

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arousal ›   hormones ›  


Q: Is there a trade-off between hot flash relief and libido?

You're wondering whether your hormone therapy, designed to address your hot flashes, is having an unintended negative effect on your libido. The good news is that adding estrogen is better for sex, in general terms. So you don't have to take back your hot flashes to get your libido back!

The less good news is that libido is sometimes a puzzle to solve. I've found that non-oral estrogen addresses hot flashes with fewer unintended effects on sexual desire. The reason is that oral estrogen enters our systems in ways that affect metabolization in the liver and resulting circulating testosterone levels. And testosterone, though not entirely understood, is as important to women's sexuality as it is to men's!

You might start by changing to non-oral or transdermal estrogen; it will likely take up to 12 weeks to see whether there's an effect. And if that doesn't make enough difference, there are other options you can explore with your health care provider.

December 09, 2013

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arousal ›   intimacy ›  


For All the Right Reasons

Had you asked Charles Darwin why people have sex, he would say that it’s all about procreation. You know, survival of the fittest and fastest breeders and all that.

Had you asked 1,500 students at the University of Texas in 2007 why they have sex, you’d have gotten 237 reasons (perhaps unsurprising, given the population) ranging from the blatantly self-centered (good exercise) to the altruistic (to please my partner).

But doesn’t the more relevant question have to do with the effect of those reasons on one’s sex life and relationship than about why a person has sex? After all, if you know that sex for your partner is simply an alternative to going to the gym, I suspect that would color your experience of sex and view of the relationship.

We know that more and better sex is linked to happiness and relationship satisfaction. But some of our motives for sex would seem to make our lives and relationships better and others to make them worse. And are there nuances within this paradigm—are some reasons for sex better than others, and is more sex always good? Finally, are there some practical applications for all this academic falderal?

Recently, in two separate studies, researchers at the University of Toronto quizzed a hundred or so dating and married couples about their reasons for having sex. The couples kept diaries for several weeks, answering questions whenever they had sex about their motivation, levels of desire, and how they felt about the relationship.

What the researchers found was that why we have sex on any given day does indeed affect how we feel about our relationship, our partner, and our level of desire. The effects were the same for both men and women, and they persisted for months after.

Responses were grouped into two main categories: approach, which seeks a positive outcome (I want to be closer to my partner) and avoidance, which seeks to circumvent something negative (I don’t want to feel guilty.) Motives for sex can also focus on oneself (I want to feel good) or one’s partner (I want to make my partner feel good.)

Researchers found that when respondents engaged in sex for partner-focused, approach motives, they felt more satisfied with the sex and better about their partner than those who had sex for self-focused, avoidance reasons.

The surprising element was that, when a person had sex for positive, partner-focused reasons, the partner also felt more positively about sex and the relationship, and that these effects persisted over time.

“If I am having sex more for approach goals, it increases my desire and satisfaction, so my partner probably senses that and it contributes to their outcome. Our satisfaction carries over to them.” says Dr. Amy Muise, lead researcher, in this article.

So it would seem that, while more sex is good, more sex for the right reasons is even better.

Of course, everyone has sex for a variety of reasons, depending on the day. Sometimes they’re positive and partner-focused (to give pleasure) and sometimes they’re negative and self-focused (to avoid guilt or conflict). And of course, we have sex when we aren’t particularly in the mood. But simply understanding the power and cumulative effect of positive, partner-focused motivation might encourage us to work on our attitude the next time our partner gets that look.

We might also work on the kind of communication and mutual respect that will make it easier for both partners to have sex for positive reasons more often. “Perhaps younger men and women still give in for this (avoidance) reasons,” says Iona Monk, counselor and founder of Vancouver Couples Counseling, in this article, “but I’d like to think it shifts as we mature, and learn to communicate better and know and accept our needs more.”

November 11, 2013

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arousal ›   women's sexual health ›  


Latebloomers: The New “Gay and Gray” Generation

Chocolate/vanilla. Black/white. Either/or. By now we know that life is a lot more nuanced. It’s an infinity of shades of gray. (Also a lot more flavors of ice cream.) Recently, a quiet phenomenon is gathering steam that challenges the either/or notion of sexuality and attraction as well as the theory that sexual orientation—our attraction to boys or girls—is pretty rigidly in place by adolescence.

They call themselves the “latebloomers.” These are women who discover well into middle age and often to their utter surprise, that they are sexually attracted to other women.

In a previous post, I wrote about some studies that examined arousal in men and women. Men, if you recall, are turned on by straight-up heterosexual sex. (Gay men are turned on by scenes of homosexual sex.) And they made no bones about their level of arousal in their self-reports, which were totally consistent with their physiological levels of arousal, as measured by blood flow to their genitals.

Women, on the other hand, were turned on by a wide variety of sexual pairing, including scenes of primates mating, according to those same instruments. But they reported that they were only aroused by heterosexual sex, which was decidedly not what their bodies were saying.

Interesting, hey?

So, that makes me wonder about this groundswell of latebloomers. By and large, they are stable, mature, married women with children who had never before been attracted to women, but who suddenly and unexpectedly found themselves with feelings they had never experienced before.

As you can imagine, this realization is like a land mine in the middle of the kitchen floor, causing tremendous upheaval, both to the woman’s identity and, if acted upon, to all her close relationships. When mamma comes out as a lesbian, it can alienate children, shock extended family, and destroy marriages. (Although interestingly some women manage to continue living with their husbands, albeit in a renegotiated relationship. Others found their husbands remarkably sanguine once they understood that it wasn’t about some shortcoming in themselves.)

Women who’ve made this transition often say it’s like discovering themselves anew. “It’s as if you spoke Chinese and lived in Mexico, then went back to China and could suddenly understand everything,” says Micki Grimland, who left a 24-year marriage after realizing she was gay in an article for More magazine. “Being straight was my second language, and I didn’t realize it until I found my first.”

Science has come a long way from the time when homosexuality was considered a mental illness. Still, sexual orientation was thought to be partly genetic and fairly hardwired by the time a person completes adolescence.

Yet, maybe things aren’t so black and white. Maybe sexual attraction isn’t so rigidly defined, at least for women. Among women in their 40s who now live with a same-sex partner, 35 percent had been married to a man. Among women in their 50s, that number is over 50 percent; and 75 percent of lesbian women over 60 had once been married.

By contrast, “almost 100 percent” of men were aware of their homosexual tendencies when they got married, according to Eli Coleman, director of the human sexuality program at the University of Minnesota in the More article. “Many women, though, are unaware of same-sex attraction until they’re much older.” And I've heard some discussion that women, who value deep emotional connections and communication, find that connectedness more readily later in life with women than men.

“The Kinsey scale shows women’s sexuality as very fluid,” says Barb Elgin, a social worker and relationship coach.

There simply isn’t enough scientific data to make any firm statements about female arousal or sexual orientation or about how changeable and fluid it may be over the course of a lifespan. At this point we’re mostly relying on anecdotal evidence. But that may be enough to suggest a cautious and compassionate approach to the issue, especially if you know, as I do, several women who have made this difficult crossing.

Because life just isn’t black or white.

September 23, 2013

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arousal ›   intimacy ›  


Amp Up Your Sexy for Autumn

Autumn can be a tremendously busy time of year when work ramps up and social obligations resume. Or it can herald a return to peaceful calm after summer frenzy.

Full disclosure: There’s nothing peaceful about autumn for me! My appointment calendar is booked solid. No fewer than three healthcare conferences are on MiddlesexMD’s schedule in the next five weeks. That’s almost a rockstar schedule! (Well, maybe an aging rock star.)

So, whether your summer is an interlude or a frenzy, autumn is nonetheless an opportunity to reevaluate your relationship, sexually speaking, and recalibrate your sizzle, if necessary.

Long-term relationships have two (at least) universal pitfalls. One is boredom; the other is neglect. Occasional boredom is the almost inevitable result of familiarity and routine. It’s the same-old, same-old. It’s our guy in oversized sweatpants with a three-day scruff; it’s us in our stained muumuu and uncombed hair. And it’s the sexual routine that is as exciting as day-old coffee.

Hard to recall those days when we could hardly wait to rip the clothes off each other, hey?

Add a stressful job, social obligations, aging parents, kids in high school or university, and the absolute last thing on our minds is sex. The first thing is sleep. So, maybe we don’t even know if we’re bored because our sex life is over there in the corner gathering dust.

“As therapists, we can vouch for the fact that when people get out of the habit of loving in a sexual way, it can be extraordinarily difficult to get back into it,” writes therapist Christine Webber and Dr. David Delvin in this article.

Your assignment, should you choose to accept it, for this autumn is to reinvigorate romance, and ultimately, your sexual relationship with this person who, once long ago, made your heart beat faster.

Notice that there’s a hint of obligation here. A robust sex life might begin with spontaneous combustion, but it requires regular and conscious refueling to keep the flame alive over the long haul.

So, the first step is to want to revive your sexual relationship badly enough to make the effort and to commit to tending the flame. Here are some tips to get started.

Anticipation is a powerful aphrodisiac, and it’s one of the first casualties of a long-term relationship. “…living together…can take the anticipation out of sex. And anticipation is not just utterly delicious in itself; it's a useful tool for heightening your passion during the act—when you finally get to it,” write Webber and Dalvin.

You can heighten anticipation by:

  • Scheduling sex. Put it on your calendar—both of you. Then you can begin to prepare—and fantasize—in advance. What will you wear? What will you do? What senses will you pleasure: what tastes, scents, textures might you incorporate? Will there be surprises? Maybe new toys? Maybe you’ll discover a new position to experiment with?
  • Prepare for your date night. Take a fragrant bath. Shave. Moisturize. Scent. Clear your mind of distractions, stress, and worry.
  • Send sexy notes. Leave them in odd places. Describe what you’re going to do to him or her. Sext like the bad girls. Email. Keep sex on the brain during the ho-hum (or hectic) work day.

One woman writes: “My husband resisted getting a cell phone for years. After becoming a small business owner, he finally caved and bought one. …After I had sent him a couple of steamy texts, he came home and said, ‘Boy, I never thought I'd say this, but I sure love cell phones!’ ”

  • Become foreplay aficionados. Nothing builds anticipation like foreplay. And you need a lot more these days, anyway. So, take your time. Tease. Play. What’s the rush?
  • Abstain. Forbidden fruit is always sweetest; the anticipation makes it so. You can touch, kiss, pet, cuddle—but no intercourse until some agreed-upon future moment.

Play. You’re only limited by your imagination here. Your date night could involve a variety of role plays: Arrange a tryst at a local bar. Arrive separately and “meet” each other. He (or you) might have conveniently reserved a room nearby. Go to a romantic movie separately and meet in the back row—make out just like you used to.

Here’s a list of adult games for both spice and romance, and honestly, they sound like fun!

Do it his way. Focus totally on pleasuring your partner. Do exactly what he wants—even if it’s not your cup of tea. Your task is to lovingly provide unforgettably erotic experience. Plan to fill in the gaps in case your partner’s imagination runs dry. Next time it’ll be your turn.

Change it up. Nothing beats boredom like a change of pace. Try different times—lovemaking in the morning, an afternoon delight. Do it in unfamiliar, maybe even [slightly] dangerous, places—on the floor in front of the fireplace, in your back yard at night, in the bathtub.

Get away—or stay at home. It’s always fun to make reservations for a weekend getaway—a nice hotel with an in-room Jacuzzi. Dinner by candlelight. A sexy, maybe erotic, film. Room service breakfast in bed.

But it can also be delicious to spend a weekend away—at home. Clear your calendar. Turn off the electronic gadgets. Get the cleaning and laundry done ahead of time. Stock up on luxurious and tasty treats that may also be known for their quality as aphrodisiacs.